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Bureaucracy, not trauma exposure, is cause of most mental health provider burnout in VA

March 24, 2015

The main culprits in mental health provider burnout in VA are workload and perceptions of organizational politics and bureaucracy, suggests VA research. (Photo: ©iStock/ClarkandCompany)

The main culprits in mental health provider burnout in VA are workload and perceptions of organizational politics and bureaucracy, suggests VA research. (Photo: ©iStock/ClarkandCompany)

The fact that mental health workers in VA suffer high rates of burnout shouldn't be surprising. Not only is VA the largest mental health care provider in the U.S., but the patients it cares for have in many cases been exposed to severe service-related trauma. Add to that the fact that VA uses psychological treatments that involve rehashing traumatic events until emotional and physical responses diminish, and what you have are mental health workers who are inundated with graphic traumatic material.

It's called compassion fatigue, and, on the surface, it makes perfect sense. Except that research on burnout rates among VA mental health providers, published online in Psychology and Psychotherapy on Jan. 21, 2015, and last year in Psychological Services found that clinician exposure to traumatic material in a therapeutic setting did not predict burnout. A third study on the topic, with similar findings, is expected to appear soon in the journal Traumatology.

"There have been studies showing that professions requiring emotion work—displaying emotion, empathizing with somebody—tend to increase stress beyond your usual job stressors," says lead study author Dr. Hector Garcia, a clinical psychologist at the South Texas Veterans Health Care System. "So we hypothesized that hearing trauma accounts would make people especially vulnerable. Listening to the most horrific events humankind can experience over and over would have an impact. As it turns out, it didn't in this sample."

That is not to say VA mental health providers didn't experience burnout. They did, and at alarming rates. Garcia used a common burnout measure that separates experiences into three dimensions: exhaustion, cynicism, and ineffectiveness. Exhaustion describes overall work fatigue. Cynicism, or indifference about work, tends to arise as a means to gain distance from work demands, says Garcia. Ineffectiveness rates how well people feel they are able to do their job. While the dimensions don't go in any particular order, it is common for employees experiencing burnout to display traits from more than one segment.

For the study, Garcia and colleagues surveyed 137 VA mental health providers in PTSD specialty clinics across the country using a burnout inventory survey. They factored in basic demographics like education, training, and absenteeism. When the data were tabulated, half of those surveyed reported high levels of exhaustion. Nearly as many (47 percent) reported high levels of cynicism. Concerns over professional efficacy were lower, around 12 percent

But if exposure to traumatic content wasn't driving burnout, what was?

Main culprits: Workload, perceptions of bureaucracy

"A portion was attributed to dealing with patients with personality disorders or those they suspected of malingering," says Garcia, also an assistant professor of psychiatry at the University of Texas Health Science Center in San Antonio. "But the most robust predictor of burnout was their perceptions of organizational politics and bureaucracy, as well as their overall workload."

The result of all that burnout? High absenteeism and high turnover, both of which are costly, not only to taxpayers, but to patients as well.

"There was a study in 2004 of a major academic hospital that found annual costs related to employee turnover were $29 million alone. It was 5 percent of their total budget. Now given that VA is the largest health care organization in the country, that's potentially billions of dollars when you take into account recruitment, human resources, training, and lost productivity," says Garcia. "Not to mention that other providers have to absorb that person's caseload when the position is vacant, resulting in even larger workloads and more burnout. Then consider that Veterans have to establish trust with a new provider."

More than 30 percent of the providers surveyed by Garcia said they were either very likely or somewhat likely to leave their position within two years. Even if only a small percentage of those actually do leave, the potential for an annual exodus of hundreds of mental health providers per year is very real.

The good news, says Garcia, is that despite the high rates of exhaustion and cynicism, mental health providers in VA, on the whole, still felt that the work they performed was effective. As long as they feel they're effective, then they'll have some protection against burnout, he says.

No easy fix

When it comes to employee burnout, particularly mental health providers, solutions don't come easy. Part of the issue lies in the very makeup of VA. As the largest health care provider in the country, VA must implement regulations and establish national standards.

"Unfortunately," says Garcia, "certain mandates tend to make employees feel over-controlled. In many cases, rules and administrative procedures need to be in place. However, employees also need to feel that they have some control over how they conduct their work. It's a difficult issue, and more research is needed into what specific aspects of 'organizational bureaucracy and politics' most impact burnout. It could be how VA manages patient scheduling, or leave requests, or even administrative measures that seem to contradict one another."

One issue not in doubt, says Garcia, is that more mental health providers are needed. At present, VA is home to 120 PTSD clinical teams staffed by 1,435 mental health care providers across the country. VA hired more than 1,600 new mental health providers in response to a 2012 presidential executive order, but Garcia says his research suggests more are needed.

"The amount of clinical work definitely predicted exhaustion, so it's clear we need to hire more staff and also give our providers time to perform non-clinical activities, whether to do research or teach or to do committee work, or even just provide protected time to staff difficult cases" says Garcia. "It's not an easy fix, but it's one that pays off in productivity and retention."

The research was funded by VA and the Department of Defense, through a grant to the STRONG STAR Multidisciplinary PTSD Research Consortium.

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